Trigeminocardiac Reflex Research Articles

Forensic aspects of sudden autopsy-negative cardiac death

The review of the world literature on the most common causes, mechanism of development and diagnostic signs of sudden autopsy-negative cardiac death is presented. Two groups of reasons for the development of this pathology were identified - traumatic and non-traumatic. The traumatic group includes the cardio-inhibitory reflex and the trigemino-cardiac reflex. The non-traumatic group included prolonged Q-T interval syndrome, Brugada syndrome, catecholaminergic polymorphic ventricular tachycardia. The importance of postmortem molecular genetic research in cases of sudden cardiac death in order to prevent the deaths in the victim's relatives is noted. The criteria for the diagnosis of reflex cardiac arrest are indicated.

Physiological responses to facemask application in newborns immediately after birth

ObjectiveApplication of a face mask may induce apnoea and bradycardia, possibly via the trigeminocardiac reflex (TCR). We aimed to describe rates of apnoea and bradycardia in term and late-preterm infants...

Territorial and Extraterritorial Trigeminocardiac Reflex: A Review for the Neurosurgeon and a Type IV Reflex Vignette.

The trigeminocardiac reflex (TCR) is a complex and, sometimes, fatal event triggered by overstimulation of the trigeminal nerve (TN) and its territorial and spinal cord branches. We reviewed and compiled for the neurosurgeon key aspects of the TCR that include a novel and straightforward classification, as well as morphophysiology, pathophysiology, neuromonitoring and neuromodulation features. Further, we present intraoperative data from a patient who developed extraterritorial, or type IV, TCR while undergoing a cervical surgery. TCR complexity, severity and unwanted outcomes indicate that this event should not be underestimated or overlooked in the surgical room. Timely TCR recognition in surgical settings is valuable for applying effective intraoperative management to prevent catastrophic outcomes.

Septorinoplasti ameliyatlarında trigeminokardiyak refleks, QT, QTc ve anestezi ilişkisi

Objective: Trigeminocardiac reflex is a reflex characterized by hypotension, bradycardia, gastric hypermotility or asystole that develops as a result of stimulation of the trigeminal nerve. In our retrospective study, in septorhinoplasty operations performed under general anesthesia, trigeminocardiac reflex development was investigated primarily during the periods where the reflex was surgically stimulated. Secondly, the effect of different inhalation anesthetic agents on the emergence of this reflex was investigated. Method: Anesthesia notes and Datex Ohmeda icentral central monitor records of septorhinoplasty cases operated between 01 / January / 2016 - 30 / November / 2016 were retrospectively examined and detected through the Hospital Information Management System software. Induction, application of local anesthesia, surgical incision, initiation of incision suturing and 5 minutes after extubation were recorded from the records. It was determined that two different inhalation anesthetics were administered in 60 patients who met the criteria, and analyzes were performed in 2 separate groups as group sevoflurane and group desflurane, and the development of QT, QTc and Trigeminocardiac reflex was investigated. Results: Although there was no difference between the groups, when the basal values were compared with the other periods, it was found that the development of TKR and QT and QTc experts were mostly observed in the periods of local anesthesia, surgical incision and incision suturing. (p <0.001) Conclusion: We think that the inhalation anesthetic agents used mostly in the sevoflurane group play a facilitating role in the development of TKR, especially by creating a cumulative effect during periods when the trigeminal nerve is maximally stimulated.

Comparing the effect of two different interfaces on breathing of preterm infants at birth: A matched-pairs analysis

ObjectiveApplying a face mask could provoke a trigeminocardiac reflex. We compared the effect of applying bi-nasal prongs with a face mask on breathing and heart rate of preterm infants at birth. MethodsIn a retrospective matched-pairs study of infants <32 weeks of gestation, the use of bi-nasal prongs for respiratory support at birth was compared to the use of a face mask. Infants who were initially breathing at birth and subsequently received respiratory support were matched for gestational age (±4 days), birth weight (±300 g), general anaesthesia and gender. Breathing, heart rate and other parameters were collected before and after interface application and in the first 5 min thereafter. ResultsIn total, 130 infants were included (n = 65 bi-nasal prongs, n = 65 face mask) with a median (IQR) gestational age of 27+2 (25+3–28+4) vs 26+6 (25+3–28+5) weeks. The proportion of infants who stopped breathing after applying the interface was not different between the groups (bi-nasal prongs 43/65 (66%) vs face mask 46/65 (71%), p = 0.70). Positive pressure ventilation was given more often when bi-nasal prongs were used (55/65 (85%) vs 40/65 (62%), p < 0.001). Heart rate (101 (75–145) vs 110 (68–149) bpm, p = 0.496) and oxygen saturation (59% (48–87) vs 56% (35–84), p = 0.178) were similar in the first 5 min after an interface was applied in the infants who stopped breathing. ConclusionApnoea and bradycardia occurred often after applying either bi-nasal prongs or a face mask on the face for respiratory support in preterm infants at birth.

TRIGEMINAL-CARDIAC REFLEX: A COMMON BUT UNRECOGNIZED PRESENTATION AMONG PATIENTS WITH EPISTAXIS

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Trigeminal-cardiac reflex (TCR), is a neurocardiogenic reflex which can produce sudden onset hemodynamic instability. We describe a case of TCR which was observed in a patient presenting with recurrent epistaxis. CASE PRESENTATION: A 71-year-old gentleman with a past medical history of hypertension and metastatic prostate cancer was admitted to the hospital with a chief complaint of persistent epistaxis. As conventional epistaxis management was unsuccessful, he underwent right-sided sphenoidal artery embolization followed by Foley catheter balloon packing. That night, he abruptly developed hemodynamic instability with a drop in his BP from 150/98 to 83/50mmHg, together with a rapid reduction in his HR by 25%. The patient was afebrile, awake, alert, and following commands. He was immediately started on empiric antibiotic therapy and received gentle fluid boluses. Workup for sepsis and cardiopulmonary etiologies of the hemodynamic changes, including complete blood count, comprehensive metabolic panel, blood cultures, chest imaging, and electrocardiogram, were obtained and were negative. His vitals rapidly returned to the baseline with conservative measures. However, within the next hour, the patient was noted to have another transient episode of a sudden drop in BP and HR. The septic and cardiopulmonary workup remained negative. On further chart review, the patient had reported pulling on the Foley packing due to irritation prior to the onset of the episodes. Therefore, the TCR reflex, induced when the patient applied traction on the Foley catheter, was the likely cause of these transient episodes of hemodynamic instability. The nasal packing was not immediately removed due to the high risk of rebleed. Continuous hemodynamic monitoring was maintained while the patient was advised to avoid manipulation of the packing. Once he became stable, the packing was removed, following which the episodes never recurred. DISCUSSION: Epistaxis is one of the most common causes of ER visits in the United States. TCR is defined as an acute reduction in heart rate and mean arterial blood pressure by more than 20% compared to the baseline and is usually triggered with manipulation near the trigeminal nerve endings [1]. In the case of our patient, there was a definite temporal relationship between the episodes of hemodynamic instability and the traction applied on nasal packing, which likely stimulated the nerve and activated TCR [2]. CONCLUSIONS: Although the clinical course of most epistaxis cases is benign, under-diagnosis of this unique brain stem reflex has resulted in severe consequences including patient death [2]. Therefore, trigeminal-cardiac reflex should be included as one of the differentials of acute hemodynamic instability in patients with nasal packing. Reference #1: Schaller BJ, Filis A, Buchfelder M. Trigemino-cardiac reflex in humans initiated by peripheral stimulation during neurosurgical skull-base operations. Its first description. Acta Neurochir (Wien). 2008;150(7):715-718. doi:10.1007/s00701-008-1602-1 Reference #2: Awasthi D, Roy TM, Byrd RP Jr. Epistaxis and Death by the Trigeminocardiac Reflex: A Cautionary Report. Fed Pract. 2015;32(6):45-49. DISCLOSURES: No relevant relationships by Suganya Chandramohan, source=Web Response No relevant relationships by Graciela Rojas, source=Web Response No relevant relationships by Joseph Sebastian, source=Web Response No relevant relationships by Josee Smith, source=Web Response

Unanticipated Asystole During Maxillofacial Surgery Due to Activation of the Trigeminocardiac Reflex: What are the Modulating Effects of Intravenous Ketamine and Remifentanil?

Unanticipated Asystole During Maxillofacial Surgery Due to Activation of the Trigeminocardiac Reflex: What are the Modulating Effects of Intravenous Ketamine and Remifentanil?

Pressure point knockouts and neurodynamics

Without understanding the underlying neurodynamics, for decades, martial artists have safely employed a phenomenon known as pressure point knockouts (PPK). PPK are low-force martial arts techniques that reversibly alter consciousness in the receiver. Beyond altered consciousness, symptoms of the PPK include pupillary dilation, pallor, diaphoresis, loss of motor control, altered respiration, and, reportedly, altered heart rate. PPK are primarily attacks to the head, frequently combined with an extremity manipulation but also include techniques to reverse the effects, known as revivals. PPK practitioners often use a series of theories drawn loosely from Traditional Chinese Medicine to explain both the attacks and revivals. This study examines PPK and then discusses two related categories of information: the trigeminocardiac reflex (TCR) and the study of neurodynamics. The trigeminocardiac reflex is an unusual constellation of autonomic effects encountered in reaction to stimulation of the trigeminal nerve. Neurodynamics recognizes that excessive mechanical tension of nerves can have adverse effects both peripherally and centrally on the nervous system, as seen in the double crush syndrome. By combining these categories, this paper proposes a theory of PPK which uses neurodynamic tension of the upper cervical spine transmitted via the myodural bridges of the suboccipital muscles, enhanced by extremity neurodynamic positioning and the double crush phenomenon, to elicit a version of the trigeminocardiac reflex. Viewed within the context of the TCR and neurodynamics, the practice of PPK presents a novel laboratory to study aspects of the treatment of difficult cranial vault and maxillofacial problems.

Brain and Heart Crosstalk During Neurointerventional Procedures: The Role of the Trigeminocardiac Reflex: An Updated Systematic Review.

The trigeminocardiac reflex is a well-described brainstem reflex that clinically manifests as bradycardia, hypotension, or apnea. This physiological phenomenon is extensively reported during open neurosurgical procedures, but very few data exist for trigeminocardiac reflex occurrence during neurointerventional procedures. This systematic review aims to provide aggregated information related to the trigeminocardiac reflex during neurointerventional procedures and to improve understanding of the various mechanisms that can incite this unique brain-heart crosstalk.

The Trigeminocardiac Reflex: The Course of the Emerged Definition over the Last 21 Years

The Trigeminocardiac Reflex: The Course of the Emerged Definition over the Last 21 Years

Reflejo trigémino cardíaco durante artroscopia de la articulación temporomandibular. Reporte de caso clínico

Introducción: el reflejo trigémino cardíaco es una respuesta fisiológica parasimpática repentina, que ocasiona alteraciones cardiovasculares importantes durante la estimulación nerviosa en el trayecto del V par craneal, generalmente ocurre al realizar procedimientos quirúrgicos en cirugía oral y maxilofacial, neurocirugía, oftalmología y dermatología. La artroscopia de la articulación temporomandibular ha sido tradicionalmente considerada un procedimiento quirúrgico seguro, mínimamente invasivo, aun así, esta técnica no está exenta de complicaciones neuro y cardiovasculares. Objetivo: presentar un caso clínico que durante una artroscopia de la articulación temporomandibular en la fase de instrumentación del espacio articular superior, y que, bajo monitoreo continuo del anestesiólogo, reportó una bradicardia súbita. Conclusión: el diagnóstico intraoperatorio de reflejo trigémino cardíaco, fue descrito por el servicio de anestesiología recibiendo un tratamiento farmacológico temprano para esta condición, lo que permitió obtener una adecuada evolución trans y postoperatoria.La artroscopia de la articulación temporomandibular ha sido tradicionalmente considerada un procedimiento quirúrgico seguro, mínimamente invasivo, aun así, esta técnica no está exenta de complicaciones.El objetivo de este artículo es presentar un caso clínico que durante una artroscopia de la articulación temporomandibular en la fase de instrumentación del espacio articular superior sufrió una bradicardia súbita, con un diagnóstico intraoperatorio de reflejo trigémino cardíaco, recibiendo un tratamiento temprano por parte del servicio de anestesiología de esta condición, obteniendo una adecuada evolución trans y postoperatoria.

The Effect of Atropine on Trigeminocardiac Reflex-induced Hemodynamic Changes During Therapeutic Compression of the Trigeminal Ganglion.

Percutaneous compression of the trigeminal ganglion (PCTG) can induce significant hemodynamic perturbations secondary to the trigeminocardiac reflex (TCR). The aim of this study was to investigate the effect of atropine pretreatment on hemodynamic responses during PCTG for trigeminal neuralgia. A total of 120 patients who received PCTG were randomly assigned to control and atropine groups that were pretreated with saline (n=60) and atropine 0.004 mg/kg intravenously (n=60), respectively. Heart rate (HR) and mean arterial pressure (MAP) were measured at 9 timepoints from before induction of anesthesia until the end of the PCTG procedure; the incidence of TCR was also observed. HR was higher in the atropine compared with control group from the time of skin puncture with the PCTG needle until after the procedure was completed (P<0.05). MAP was also higher in the atropine compared with control group, but only at entry of the needle into the foramen ovale until 1 minute after trigeminal ganglion compression (P<0.05). HR was reduced in both groups during entry of the needle into the foramen ovale and during ganglion compression, but less so in the atropine compared with the control group (P<0.05). MAP increased during PCTG compared with baseline in both groups, but with a larger increase in the atropine group (P<0.05). Two and 52 cases in the control group, and 6 and 1 cases in the atropine group, exhibited a TCR during entry of the needle into the foramen ovale and at ganglion compression, respectively (P<0.05). Pretreatment with atropine was effective in most patients at minimizing abrupt reduction in HR during PCTG.

Isolated Bradycardia During Aneurysmal Clipping: Rebleed or Trigeminocardiac Reflex?

AbstractThe most common cause of nontraumatic subarachnoid hemorrhage is the rupture of intracranial aneurysm. After initial bleed, the risk of rebleeding is highest in the early postictal period and this rebleed is strongly associated with poor neurological outcome. The major goal of anesthesia in these surgeries is to prevent the rebleed. If rebleeding occurs prior to the craniotomy, it results in the acute rise of intracranial pressure and usually presents as bradycardia and hypertension (Cushing’s reflex). Here we reported a case where rebleeding presented unusually as isolated bradycardia without associated hypertension and was mistaken as trigeminocardiac reflex. The surgeon was informed about the event and they planned to proceed. After craniotomy, despite all the efforts the brain was persistently tight and surgery could not be completed. Postoperative scan showed rebleeding and the patient died after a few days in ICU.We highlighted in this case report the fact that isolated transient bradycardia may also be the presentation of rebleed with closed cranial vault. It is not always necessary to see all the features of Cushing’s traid in every patient. If bradycardia occurs before the craniotomy, the surgeon should be notified, the severity of bleed should be assessed, and further management should be planned according to the severity of bleed.

Second Impact Syndrome. Myth or reality?

IntroductionSecond impact syndrome (SIS) is a devastating condition occurring in sport-induced mild brain injury. SIS is drastically defined by anamnestic, clinical and radiological criteria, which is unusual in the field of cranial traumatology. The purpose of this study was to provide a literature review of this syndrome. Material and methodsWe conducted a literature review of all published studies on PubMed. The keywords were “second impact syndrome and catastrophic head injury”, “second impact syndrome and sport”, “repeat concussion and catastrophic brain injury”, “catastrophic head injury and concussion”, “catastrophic head injury”, “concussion and second impact syndrome”, “concussion and repetitive head injury”. ResultsEighty-two full-text articles were assessed for eligibility. Finally, 41 studies were included in qualitative synthesis and 21 were included in quantitative synthesis. DiscussionThe number of cases reported in the literature was extremely small compared to the population at risk, i.e., the number of athletes exposed to repeated concussions. SIS was similar to talk and die syndrome, with which it shares certain characteristics. If we consider SIS according to “talk and deteriorate tables”, it opens up interesting perspectives because they are specific in children and adolescents. Taking into account the scarcity of this syndrome, one may question whether athlete-intrinsic features may be involved in at least some cases of SIS. On a pathophysiological level, many explanations remained unsatisfactory because they were unable to explain all the clinical phenomena and observed lesions. Triggering the trigeminocardiac reflex is a crucial element in explaining the sequence of clinical events. Its association with a state of neurogenic inflammation provides an almost complete explanation for this particular condition. Finally, on a practical level, a concussion occurring during the playing of a sport must be considered as any other injury before allowing a return to play.

Asystole triggered by the trigeminocardiac reflex following posttetanic count stimulation of the facial nerve: A case report.

Asystole triggered by the trigeminocardiac reflex following posttetanic count stimulation of the facial nerve: A case report.

Ganglionic trigeminocardiac reflex: A less known presentation of a well-known entity

Ganglionic trigeminocardiac reflex: A less known presentation of a well-known entity

Changes of sensory and pain thresholds in healthy subjects after mandibular extension at maximum mouth opening: implications for temporomandibular disorders therapy.

There is evidence showing that increasing the vertical dimension of occlusion, or interocclusal distance, reduces pain symptoms in patients with temporomandibular disorders (TMD) and bruxism. The mechanism underlying the analgesic effect is still under investigation. Some researchers propose either a gate mechanism or the activation of the trigemino-cardiac reflex. In this study, sensory and pain thresholds changes in the mandibular district have been evaluated in twenty healthy subjects immediately after 5 minutes of mandibular stretching at maximum opening of the jaw. Results showed a 60% increment in sensory threshold and a 70% increment in pain threshold (p<0.001) compared with the baseline values. The magnitude of the analgesic effect seems proportional to the extent of mandibular opening. These and similar results are discussed as for the implication in the treatment of TMD related symptoms.

A case of sinus arrest caused by trigeminocardiac reflex during mouth-opening exercises

A case of sinus arrest caused by trigeminocardiac reflex during mouth-opening exercises

Trigeminocardiac reflex and anesthesia

Trigeminocardiac reflex (TCR) is a well-established brain stem reflex that manifests as sudden cardiac perturbations, including bradycardia, arterial hypotension, asystole, apnea, and gastric hypermobility by surgical stimulation. The intense episode of the TCR is life-threatening. It has been widely concerned by anesthesiologists because of the great amount of surgeries could be involved in TCR and the high incidence of TCR. This review summarized the definition, pathological mechanisms, classification, incidences and its correlation with anesthesia, prevention, treatment and prognosis of the TCR so as to provide a reference for anesthesiologists to recognize and manage the TCR in time during general anesthesia. Key words: Trigeminocardiac reflex; Anesthesia

Cardiovascular Collapse in a Patient With Parotid Abscess: Dangerous Cross Talk Between the Brain and Heart: A Case Report

Postsurgical trigeminal neuralgia (TN), although rare, can lead to significant hemodynamic perturbations by triggering the trigeminocardiac reflex (TCR). The combination can lead to diagnostic as well as management challenges for clinicians. We present the case of a patient with a parotid abscess, which developed as a complication of his otolaryngologic surgery, and which led to repeated episodes of symptomatic bradycardia associated with cardiovascular collapse. This case highlights the importance of heightened awareness, early diagnosis, and timely treatment of postsurgical neuropathic pain syndromes to avoid life-threatening complications.